Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oaks, The during CMS and state inspections, most recent first.
A resident with OSA, COPD, CHF, chronic respiratory failure with hypoxia, and morbid obesity did not receive the recommended BiPAP machine. Pulmonology records noted the resident had not been using BiPAP because of missing parts, later provided only a full-face mask, and reported that the nursing home had taken away the BiPAP device. Facility staff did not clarify the consultant report or follow up on the BiPAP equipment, and the resident stated only a mask was in the room with no CPAP or BiPAP machine.
Incomplete Weekly Skin Integrity Documentation: Two residents who were at risk for pressure ulcers/injuries had weekly skin check UDAs signed off as completed on the TAR, but the electronic Weekly Skin Integrity Data Collection records did not show the assessments were documented beyond earlier dates. Nursing staff and unit managers stated the skin checks should be completed weekly and documented in the EMR, and one unit manager said the checks had been done but not documented.
The facility failed to act on pharmacist recommendations from monthly Medication Regimen Reviews for three residents. Issues included lack of stop dates for PRN medications, failure to clarify medication orders, and not addressing potential medication contributions to falls. The facility did not ensure timely review and implementation of recommendations, and staff interviews revealed a lack of a tracking system to address these issues.
The facility failed to limit PRN psychotropic medications to 14 days for three residents, as required. A resident received PRN Ativan beyond the 14-day limit without a physician's documented rationale. Another resident was given PRN Trazodone, Ativan, and ABH gel without proper documentation or evaluation. A third resident received PRN Trazodone more than 15 times after the initial period without re-evaluation. Staff interviews revealed a lack of adherence to the policy on PRN psychotropic medications.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak on the Maplewood Unit, as residents were not tested every 48 hours as required. Additionally, during a wound dressing change for a resident, the Infection Control Nurse did not establish a clean surface for supplies, leading to potential cross-contamination. The Corporate Staff Development Coordinator Nurse acknowledged the issues, but the Infection Control Nurse admitted to often performing dressing changes alone due to a lack of assistance.
A resident received PRN Tylenol without a complete medication order, as the strength of the acetaminophen tablet was missing. Despite this, the medication was administered multiple times. Facility staff, including the DON, acknowledged that the order should have been clarified before administration, as all medication orders must include full instructions. The issue was noted during pharmacist reviews but was not corrected promptly.
Failure to Obtain Ordered BiPAP Equipment
Penalty
Summary
The facility failed to follow the pulmonologist’s recommendation to obtain a BiPAP machine for a resident with obstructive sleep apnea, COPD, chronic diastolic CHF, chronic respiratory failure with hypoxia, and morbid obesity. The resident was cognitively intact and receiving oxygen therapy, and stated that he or she was supposed to be using a BiPAP machine for breathing problems but did not have one and instead used an oxygen mask while in bed. The resident’s pulmonology records showed a recommendation for a sleep study with BiPAP titration, and later office notes documented that the resident had not been using the BiPAP because of issues obtaining parts for the machine. At a pulmonology visit, the resident was fitted for a full-face mask, size large, but did not bring the CPAP machine, and the office manager stated the office does not supply machines and sends referrals to a durable medical supply company. Another pulmonology note later stated the resident reported the nursing home had taken away the BiPAP device and that he or she no longer had one at the nursing home. Facility staff were aware the resident had been scheduled for pulmonology testing and CPAP fitting, but the unit manager stated she was not aware of any information for a BiPAP machine and did not follow up when the consultant report did not clearly address it. The DON stated nurses should review consultation forms and follow up with the consultant if the report is unclear, and said they would follow up on the BiPAP machine. The resident continued to report having only the mask in the drawer and no CPAP or BiPAP machine in the room.
Incomplete Weekly Skin Integrity Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records in accordance with accepted professional standards for two residents who were at risk for pressure ulcers/injuries. Resident #79, admitted with diagnoses including dementia and peripheral vascular disease, had a physician order for a weekly vital signs/progress note/skin check UDA. Although the January through March 2026 TAR showed the skin check UDA was signed off as completed each week, the Weekly Skin Integrity Data Collection UDA showed the last assessment was completed on 1/12/26. Resident #104, admitted with a diagnosis including dementia, also had a physician order for a weekly vital signs/progress note/skin check UDA. The January through March 2026 TAR showed the skin check UDA was signed off as completed each week, but the Weekly Skin Integrity Data Collection UDA showed the last assessment was completed on 1/18/26. During interviews, nursing staff and unit managers stated that skin assessments should be completed weekly and documented electronically as a Weekly Skin Integrity Data Collection UDA, and one unit manager said the skin checks had been completed but were not documented.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that irregularities identified by the pharmacist during the monthly Medication Regimen Review (MRR) were reviewed and acted upon in a timely manner for three residents. For one resident, the facility did not clarify the as-needed acetaminophen order by adding a strength and failed to add a stop date to the PRN Ativan/Lorazepam. The physician signed the MRR but did not document a rationale for extending the PRN Ativan beyond 14 days, and the facility did not update the orders in the medical record until after repeated recommendations. Another resident had multiple issues with medication orders, including the lack of stop dates for PRN Trazodone and Ativan, and the continued use of Methenamine despite a new order for Cefuroxime indicating the former may not have been effective. The MRR reports were unsigned by the physician, and the facility did not document a rationale for continuing PRN psychotropic medications beyond 14 days. Additionally, the facility failed to address recommendations regarding the use of ABH Gel, an antipsychotic, which should have been limited to 14 days per CMS requirements. A third resident experienced a fall, and the pharmacist recommended evaluating Seroquel as a possible contributor. The MRR report was initially unsigned, and the recommendation was repeated in subsequent reviews. The physician eventually declined the recommendation, but the facility did not ensure timely review and implementation of MRR recommendations. Interviews with staff revealed a lack of a tracking system to ensure MRR recommendations were addressed, and the DON was unaware of repeated and unaddressed recommendations.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free from unnecessary psychotropic medications, specifically regarding the use of PRN (as needed) orders. For three residents, the facility did not limit the use of PRN psychotropic medications to 14 days, nor did they ensure that a physician evaluated and documented a rationale for continued use beyond this period. This oversight was identified during a review of records and interviews with staff. Resident #1 was prescribed PRN Ativan for anxiety, but the medication was administered beyond the 14-day limit without a documented rationale from a physician. The initial order was not reviewed or discontinued on time, and subsequent orders were extended without proper documentation or evaluation. Similarly, Resident #2 was prescribed PRN Trazodone and Ativan, as well as ABH gel, but these medications were also administered beyond the 14-day limit without appropriate documentation or physician evaluation. The facility did not ensure that these medications had stop dates or that a rationale for their continued use was documented. Resident #90 was prescribed PRN Trazodone for anxiety, which was administered more than 15 times after the initial 14-day period without a documented re-evaluation or rationale for continued use. Interviews with facility staff, including nurses and the Director of Nursing, revealed a lack of awareness and adherence to the policy that PRN psychotropic medications should be limited to 14 days unless a physician provides a documented rationale for extension. The facility's failure to comply with these guidelines resulted in the administration of unnecessary medications to residents.
Infection Control Deficiencies During COVID-19 Outbreak and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak on the Maplewood Unit. The facility did not adhere to the required testing frequency for residents potentially exposed to COVID-19. According to the Massachusetts Department of Public Health guidelines, residents should be tested every 48 hours until the facility goes seven days without a new case. However, the review of the Maplewood Unit Resident Testing indicated that testing did not occur every 48 hours as required. Interviews with the Infection Control Nurse, Unit Manager, and Director of Nurses revealed that testing was not scheduled in the Resident Assessments, Medication Administration Record, or Treatment Administration Record, and staff relied on verbal communication to know when to test residents. Additionally, the facility failed to adhere to infection control procedures during a wound dressing change for a resident with a laceration and local infection of the skin. The Infection Control Nurse did not establish a clean surface for the dressing supplies, which were placed directly on the resident's bed blanket and the floor. The nurse also handled the outside surfaces of multiple packages of supplies that were in direct contact with the bed blanket, and did not change gloves after handling these supplies. Blood from the wound was observed running down the resident's leg onto the floor, and the nurse did not use a fluid-impermeable pad to prevent contamination. The Corporate Staff Development Coordinator Nurse acknowledged the infection control issues and stated that the facility had enough supplies and resources for the dressing change to be performed correctly. However, the Infection Control Nurse admitted to not establishing a clean surface and often performing dressing changes alone due to a lack of available assistance. These actions and inactions contributed to the facility's failure to maintain a safe and sanitary environment, potentially increasing the risk of cross-contamination and infection transmission.
Incomplete Medication Order Leads to Deficiency
Penalty
Summary
The facility failed to provide care and services consistent with accepted standards of clinical practice for a resident, specifically in the administration of PRN Tylenol. The physician's order for the medication was incomplete as it did not include the strength of the acetaminophen tablet, which is a necessary component for a valid medication order. Despite this omission, the medication was administered on multiple occasions as recorded in the May and June Medication Administration Records (MARs). Interviews with facility staff, including a Unit Manager and the Director of Nurses (DON), confirmed that all medication orders should include full instructions, such as strength, dose, frequency, and route. The staff acknowledged that the order should have been clarified before administration, and the medication should not have been given as the order was incomplete. The issue was identified during monthly pharmacist medication regimen reviews, but the order was not corrected until a later date.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near New Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At New Bedford | 2.8 mi | ★★★★★ | 0 | 0 |
| Alden Court Nursing Care & Rehabilitation Center | 5.7 mi | ★★★★★ | 0 | 0 |
| Hathaway Manor Extended Care | 6.3 mi | ★★★★★ | 1 | 0 |
| Sacred Heart Nursing Home | 6.4 mi | ★★★★★ | 3 | 0 |
| Royal Of Fairhaven Nursing Center | 6.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.